| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 has a diagnosis of ASD, Mild ID, ODD, Mood Disorder, Tic Disorder, and ADHD. Individual #1 lived in their own apartment until 7/1/24, when an emergency consolidated waiver was approved as Individual #1 had a PFA filed against them from a former paramour. Individual #1 has a history of self-neglect, including not taking medications or skipping medications, as recently as February 2024. Individual #1's most recent Individual Support Plan (ISP) update before their 7/1/24 admission stated that, "[Individual #1] is still learning what their medications are, when to take them, and the reason for taking them." This is confirmed in Individual #1's initial assessment completed by Sunny Days on 8/27/24.
Individual #1 has been self-administering their medications since their 7/1/24 admission to Sunny Days. There are no Medication Administration Records kept. Staff are to note when the individual takes their medications daily, but according to the records, Individual #1 is not consistent in taking their medications at the correct times. For example, morning medications have been taken anywhere from 8am to 1pm. On 11/26/24, Individual #1 took their evening medications in the morning. No follow up action was taken. On February 9, 2025, Individual #1 did not take their morning medications, and then was upset that staff reminded the individual to take their evening medications late. Individual #1 did not take their morning medications on 2/26/25. No follow up action was taken with any of these missed administrations.
Many of the staff who work in Individual #1's home are not medication administration trained. Allowing Individual #1 to self-administer medication when they have not been safely assessed to complete this task independently creates conditions conducive to serious harm for Individual #1. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Staff will administer Individual #1's medications until Individual #1 can consistently demonstrate that they can
1. Recognize and distinguish their medication. 2. Know how much medication is to be taken. 3. Know when the medication is to be taken. 4. Take or apply the medication with or without the use of assistive technology.
Initiate Medication Administration Records (MARs) for documentation of daily medication intake.
Require all staff working in Individual #1's home to complete medication administration training.
Train staff on how to properly document and report missed or incorrect medication administrations.
Assign a lead staff member responsible for medication oversight and follow-up actions.
Implement a protocol for addressing missed doses, including notifying healthcare providers and updating care plans.
Conduct regular reviews of medication adherence trends to identify patterns and develop corrective strategies.
Provide additional education to Individual #1 about the importance of proper medication adherence.
Develop educational materials and visual aids to help Individual #1 understand their medications, including why and when to take them.
Offer guided self-administration support sessions to reinforce proper medication-taking behavior.
Encourage participation in medication management discussions to increase Individual #1's engagement and accountability.
Implement routine audits of medication documentation for accuracy and compliance.
Hold regular meetings with healthcare providers to review progress and adjust strategies as needed.
Establish clear procedures for ongoing staff training and policy updates. |
05/05/2025
| Accepted |
| 6400.18(b)(2) | The medication errors described in 6400.167a1 and 6400.167a4 were not reported in the department's incident management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | a. (WHO) Responsible person(s):
-Program specialist.
-Residential DSP's
-Residential House Managers
b. (WHAT) All Residential staff will be re-trained on timely reporting of incidents. All incidents, including medication errors, will be reported to EIM in a timely manner.
c. WHEN and HOW (usually attached as procedure)
Sunny Days IM Point Person will re-train all staff on timely reporting of incidents, including medication errors. This training will be completed by 4/15/2025. All medication errors will be reported to EIM within 24 hours of occurrence. |
04/15/2025
| Accepted |
| 6400.32(c) | Individual #1 makes poor safety and social decisions per their ISP. The individual has walked long distances at night and provided personal information to strangers. Individual #1 is to always be within line of sight of staff when in the community.
Individual #1 worked various jobs in the community in October, November, and December 2024. Individual #1 was dropped off at work, without a staff member present, for anywhere from 2 to 6 hours a total of at least 31 times between October 1, 2024, and December 31, 2024. This lack of supervision left Individual #1's safety at serious risk.
Individual #1 was prescribed doxycycline on 12/2/24. On 12/8/24, staff noted that ½ a doxycycline was found outside on the porch. There was no investigation completed to determine where the medication came from or if Individual #1 had been failing to take their prescribed medication for pneumonia. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | a. (WHO) Responsible person(s):
-Program specialist.
-Supports Coordinator
- Behavior Support Specialist
Individual #1 has a Restrictive Plan, approved by HRC on 1/8/2025 requiring them to have the support and supervision of an employment specialist for all employment activities. The employment specialist will stay with them during the entirety of their employment activities. They are trained in the BSP and will provide supervision while the individual completes job related activities. In the event that the employment specialist is not available, Sunny Days will utilize their back up plan to ensure that Individual #1 has supervision to go to work.
A fade plan is associated with this restrictive procedure, and Individual #1's ISP will be updated to modify supervision needs while working in the community as needed. The ISP team meets at least monthly to review progress in this area. While in the community not working residential staff will provide supervision. |
05/01/2025
| Accepted |
| 6400.32(g) | Individual #1 was told on 11/18/24 that they would now have "designated shopping days." Individual #1 was not in agreement with this, and on 11/30/24 requested to not have designated shopping days. On 11/20/24, 12/3/24, and 12/26/24, Individual #1 requested to go in the community to go shopping and do preferred activities, but was not allowed to go because it was not a "designated shopping day." | An individual has the right to control the individual's own schedule and activities. | a. (WHO) Responsible person(s):
-The program specialist.
-Residential DSP staff
-Residential House Manager
b. (WHAT) Individual #1's BSP will be updated to include historical and diagnostic information supporting the designated outing days that Individual #1 prefers. The plan will detail the reasons why these planned days are important to Individual #1 and will also identify staff responsibilities to ensure that the individuals rights are not restricted. It will be clarified that the individual can go out at any time, not only on the days that were planned out.
c. WHEN and HOW (usually attached as procedure)
Individual #1's BSP will be updated by 5/1/25 and all staff will be trained on the updates by 5/5/25. |
05/05/2025
| Accepted |
| 6400.32(u) | Individual #1 began showing signs of illness on 11/21/24. These symptoms included coughing, vomiting, and UTI symptoms. On 11/24/24, Individual #1 asked to go to the ER, but was denied. These symptoms continued, and a fever began on 11/28/24. Individual #1 again asked to go the doctor on 11/29/24 but was told no. Symptoms continued, and on 12/1/24, Individual #1 was once again denied a requested doctor's visit. On 12/2/24, Individual #1 was finally taken to the doctor, where the individual was diagnosed with pneumonia and prescribed an antibiotic. | An individual has the right to make health care decisions. | a. (WHO) Responsible person(s):
-Program specialist.
-Residential DSP staff
-Residential House Manager
In the event that at any time Individual #1 reports to staff that they are sick, not feeling well, wishing to go to the hospital, etc, Station MD will be utilized. Station MD will help to assist staff in the determination of the level of care needed, by a healthcare professional. If Individual #1 wishes not to utilize Station MD, the health care concern will be addressed immediately using other options such as seeing their PCP, Urgent Care, or the ER. |
05/01/2025
| Accepted |
| 6400.52(c)(6) | Individual #1 has an Individual Support Plan (ISP), Behavior Support Plan (BSP), and has a new diagnosis of Borderline Personality Disorder (BPD) that staff are to be trained on before working with Individual #1.
· Staff persons #8 and #10 have not been trained on Individual #1's BSP.
· Staff persons #7, #10, #11, and #13 have not been trained in BPD. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | a. (WHO) Responsible person(s):
-The program specialist
-Residential House Managers
b. (WHAT) All staff will be trained on an individual's BSP and sign the corresponding training sheets before working with an individual.
c. WHEN and HOW (usually attached as procedure)
All staff will be trained by the program specialist or author of the behavior plan before working with an individual. The house manager will be responsible for ensuring that the program specialist is aware of the new staff's training schedule. |
04/15/2025
| Accepted |
| 6400.162(a) | Individual #1 is self-administering their medication, however, they have not properly been assessed to complete this administration on their own. A total of 13 staff have worked in the home between 9/1/24 and 2/28/25. Only 5 of these staff are trained in medication administration. Additionally, Individual #1 receives a zepbound subcutaneous injection weekly that is to be administered by staff. It is not able to be determined who administers this medication each week, and so it cannot be verified that qualified staff are administering this medication. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | a. (WHO) Responsible person(s):
-The medication administration trainer. They created a Sub-Q injection Medication Administration Record.
-All staff who are trained by a licensed medical professional to administer Sub-Q injections have been trained on the new form and their responsibilities for documenting all Sub-Q injections.
b. (WHAT) A medication administration record for Sub-Q Injections will be used to document all Sub-Q injections. Staff will indicate if they administered the injection, or if they observed an individual self-administering the injection. Only staff trained by a licensed medical professional will administer Sub-Q injections. Individual #1 is no longer prescribed any medications that are to be injected subcutaneously, so no updated record filled out by their staff is available.
c. WHEN and HOW (usually attached as procedure)
The Sub-Q Medication Administration Record was created on 4/3/2025. All staff who are trained by a licensed medical professional to administer Sub-Q injections were trained on 4/3/2025 on their responsibilities for documenting the administration of Sub-Q injected medications. Training records for this training are Attachment JK5. Training records for staff who have been trained by a licensed medical professional to administer Sub-Q injections are retained with their annual medication administration practicum.
All residential records have been reviewed for individuals who receive Sub-Q injections via unlicensed direct support staff, and these changes will apply to all individuals supported residentially. |
04/03/2025
| Accepted |
| 6400.166(a)(4) | Individual #1 is self-administering their medication, however, they have not properly been assessed to complete this administration on their own. Individual #1's date of admission to Sunny Days was on 7/1/24. There have not been Medication Administration Records kept for Individual #1's medications since their date of admission. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | a. (WHO) Responsible person(s):
- The medication administration trainer.
b. (WHAT) Individual #1 has been working on their ISP outcome of self-administering medications since their admission on 7/1/2024. They were assessed on 7/1/2024, and they are assessed weekly when filling their med minder for the week with staff. It was discussed with their legal guardian and ISP team that they were losing a lot of rights by moving into the group home, and retaining the right to self-administer their medication was not one of the rights that did not need to be stripped from them. The team anticipated that they would have more success with administering their own medications with the supervision and support of staff. DSP staff and the house manager will be re-trained on Sunny Days medication self-administration policy. Written instructions from Individual #1's doctor will be attached to the record so that they are allowed the dignity of risk in choosing what time they take their medications, within doctor's orders. While the individual continues to work towards the outcome of self-administering their medications, staff will continue to observe the individual taking their medications and record the time of each administration. If Individual #1 fails to take their medication within the times recommended by their doctor, a med error will be reported to EIM. The Med-Minder Support form that is filled out by a staff who has completed the Medication Administration Training program by DHS when Individual #1 fills their weekly med-minder contains the required information for a Medication Administration Record (Name of medicine. Strength of medication. Dosage form. Dose of medication. Route of administration. Frequency of administration. Administration times. Diagnosis or purpose for the medication, including pro re nata. Duration of treatment, if applicable. Special precautions, if applicable. Side effects of the medication, if applicable.) When Individual #1 takes their medication, a log is signed by staff who observe them taking their medication, indicating the date and time of administration by the individual.
c. WHEN and HOW (usually attached as procedure)
Sunny Days Medication Self-Administration policy is Attachment JK1. It was updated on 4/8/2025 to include individuals who are working towards self-administration of medication as an outcome. Staff were re-trained on this policy on 4/8/2025. The training sheet for this training is Attachment JK2. All records for individuals residing in Sunny Days group homes were reviewed, and staff working in homes where individuals self-administer medications were re-trained on the Medication Self-Administration policy on 4/8/2025. These training sheets are included with Attachment JK2. |
04/08/2025
| Accepted |
| 6400.167(a)(1) | Individual #1 was not administered their morning medications on 2/9/25 and 2/26/25. | Medication errors include the following: Failure to administer a medication. | Investigate why the medications were missed (e.g., staff oversight, scheduling issue, system error).
Interview staff involved to gather insights on what led to the non-administration.
Review medication administration procedures and documentation practices.
Provide refresher training on medication administration protocols.
Reinforce the importance of timely documentation and adherence to medication schedules.
Ensure all staff understand the consequences of missed medications and how to prevent errors.
Plan to Maintain Compliance
Enhanced Monitoring & Documentation:
Implement a double-check system where another staff member verifies medication administration.
Use electronic alerts or reminders for scheduled medications.
Maintain detailed documentation to ensure accountability.
Policy Review & Updates:
Revise medication administration policies to address potential gaps.
Clarify procedures for handling missed doses and reporting incidents.
Conduct regular audits to monitor compliance.
Accountability Measures:
Assign a dedicated staff member to oversee medication administration compliance.
Establish a reporting mechanism for missed doses and corrective actions taken.
Implement periodic compliance checks to ensure adherence to medication schedules. |
05/05/2025
| Accepted |
| 6400.167(a)(4) | On 11/26/24, Individual #1 took their evening medications in the morning. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Investigate why the medications were missed (e.g., staff oversight, scheduling issue, system error). Interview staff involved to gather insights on what led to the non-administration. Review medication administration procedures and documentation practices. Provide refresher training on medication administration protocols. Reinforce the importance of timely documentation and adherence to medication schedules. Ensure all staff understand the consequences of missed medications and how to prevent errors. Plan to Maintain Compliance Enhanced Monitoring & Documentation: Implement a double-check system where another staff member verifies medication administration. Use electronic alerts or reminders for scheduled medications. Maintain detailed documentation to ensure accountability. Policy Review & Updates: Revise medication administration policies to address potential gaps. Clarify procedures for handling missed doses and reporting incidents. Conduct regular audits to monitor compliance. Accountability Measures: Assign a dedicated staff member to oversee medication administration compliance. Establish a reporting mechanism for missed doses and corrective actions taken. Implement periodic compliance checks to ensure adherence to medication schedules. |
05/05/2025
| Accepted |
| 6400.167(d)(1) | Individual #1 ingested their evening medications in the morning on 11/26/24. This was not as the prescriber directed, and the prescriber was not contacted after this medication error occurred. | A medication error shall be reported to the prescriber under any of the following conditions: As directed by the prescriber. | a. (WHO) Responsible person(s):
-The medication administration trainer.
-Residential house manager
-Residential DSPs.
b. (WHAT) All Residential staff will be re-trained on timely reporting of incidents. All incidents, including medication errors, will be reported to EIM in a timely manner. This process will ensure that the doctor is contacted for instructions after the error occurs.
c. WHEN and HOW (usually attached as procedure)
Sunny Days IM Point Person will re-train all staff on timely reporting of incidents, including medication errors. This training will be completed by 4/30/2025. All medication errors will be reported to EIM within 24 hours of occurrence. |
04/30/2025
| Accepted |